Cosmetic Procedures

As we age, gravity works against us and our skin loses its elasticity, causing eyelids to droop and fatty tissue to accumulate below the eyes. Even with the best skin care and sun protection, aging eyes are inevitable.

One of the five most common cosmetic procedures, blepharoplasty, or eyelid surgery, can restore a healthy and youthful appearance, with a firmer and more attractive eye area. Most patients find blepharoplasty to be surprisingly easy and are pleased with its dramatic, long-lasting effects, making them look rested, refreshed and more alert.Types of Blepharoplasty
Blepharoplasty may be performed on the upper and/or the lower eyelids. There are several different methods to treat the eyelids lids, depending upon the patient’s anatomy and concerns.

In upper and lower eyelid surgery, the excess, sagging skin is removed along with any excess fat it needed. As the membrane under the lower eyelid weakens with age, fatty tissue bulges forward, causing puffiness or "bags" to form under the eyes. Transconjunctival blepharoplasty addresses this by removing the fatty tissue under the lower eyelid without the need for an incision on the eyelid.

A skin pinch lower eyelid blepharoplasty may be used to remove excess skin alone, or at the time of the tranconjunctival lower eyelid blepharoplasty to remove the excess fat as well.

A skin muscle flap lower lid blepharoplasty has the potential of removing skin, fat, AND tightening the lower lid, if needed.

In most cases, these are cosmetic procedures that are not covered by insurance. However, when drooping upper eyelids cause vision obstruction (a medical condition called “ptosis”), upper lid blepharoplasty may be covered by insurance.Combining Blepharoplasty with Other Procedures
Many patients elect to have upper and lower lid surgery together. If a patient has ptosis (drooping eyelids that interfere with vision), their upper eyelid surgery may be covered by insurance, while the patient remains responsible for the cosmetic lower eyelid procedure.

Blepharoplasty is often combined with another cosmetic procedures, such as a brow or facelift to achieve the desired results in one sitting.

Surgical Risks
All surgical procedures carry inherent risks, such as the possibility of infection. Sometimes, blepharoplasty patients have difficulty closing their eyes when asleep. Although this condition is quite rare, it may be permanent. Lower lids may droop or look pulled down. This condition, called “ectropion,” may require additional surgery.

Other potential complications include hematoma (an accumulation of blood under the skin) and changes in sensation around the eye area.

The brow and forehead are often the first facial areas to show signs of aging. Weather, the pull of gravity and years of facial expressions affect the face, resulting in frown lines, wrinkles across the forehead, deep furrows between the eyes and a droopiness of the brows and upper lids. Brow lifts, also known as forehead lifts, are often combined with upper eyelid surgery (blepharoplasty) and/or a mini facelift to rejuvenate your look.

The procedure usually takes a few hours to complete and is typically performed under local or general anesthesia. There are several different techniques for brow lifting (endoscopic brow lift, coronal brow lift and pretrichial lift), and there are many factors to consider when choosing a technique. Your surgeon will work with you to determine what type of lift is best for to achieve your goals.

Insurance does not generally cover cosmetic surgery. However, surgery to correct sagging brows and eyelids that interfere with vision may be covered in whole or in part by your insurance company.
Surgical Risks
Brow lifts are minimally invasive procedures with a complication rate of less than one percent. Nonetheless, brow lifts do carry certain risks. There may be itching and numbness at the sites of the incisions. This usually subsides within a few weeks. Infection, bleeding and other minor complications are possible. In rare instances patients may not be able to move their eyebrows or forehead. This may be corrected with additional surgery. Scarring is usually minimal, and any scars would be hidden within the hair.

Losing facial volume is a natural part of the aging process. Volume loss, along with the descent of facial soft tissues causes depressions or wrinkles to develop under the eyes and along the smile lines. One way to counter this early sign of aging is to restore fullness to the cheeks to achieve a more youthful look of high cheekbones to the face.

The use of injectable fillers is a one way to restore the contour of a youthful face and to erase fine lines and wrinkles. This is done in the office without the need for incisions. Most patients return to work the same day.

For patients interested in a more permanent option, fat augmentation is a procedure in which the surgeon transfers your own fat to restore lost facial volume. Fat augmentation is performed in the office under local anesthesia, or the procedure may be combined with a facelift in the operating room.

Ear lobe tears and elongated earring holes are very common. Thankfully, this trauma can be repaired quite easily in the office under local anesthesia. Most often, tears and elongated holes occur gradually from wearing heavy earrings over time, or from having an earring traumatically pulled on. No matter the cause of the ear lobe deformity, a surgeon can correct the tear or elongation with a very minor surgical procedure. Following the procedure, sutures will need to stay in place for one week. Then, after allowing a month for the ear lobe to heal, the ear is re-pierced.

Another reason for earlobe repair or reduction is that earlobes commonly lengthen with age. Many men and women are bothered by the elongated, aged appearance of their earlobes. The size of the ear lobe can be reduced in the office under local anesthesia. Following the procedure, sutures will need to stay in place for one week. Then after allowing a month for the ear lobe to heal the ear is re-pierced if desired.
View pre- and postoperative instructions for ear lobe repair or reduction surgery.

Many patients are concerned about the loss of their youthful neck and jaw lines. Others are concerned with extra neck skin, sagging cheeks and wrinkles in the jowl area. Any combination of these concerns may be addressed with facelifting. It is important to discuss all areas of concern with your surgeon, so that a treatment plan may be created that takes into account your personal goals and lifestyle. Once your surgeon understands your expectations, mutual, realistic goals may be set.

Mini Facelift
The mini facelift has many different names — the mini, the weekend lift, the S-lift. All of these names refer to a variation of facelifting surgery that is less invasive than a traditional facelift and may be performed under local anesthesia.

The mini facelift has an age-diminishing effect, making patients look younger, rested and more energized. This is achieved by repositioning the skin on the lower face to eliminate sagging and droopiness. The mini facelift does not require general anesthesia (though, general anesthesia is available upon request). Patients who undergo a mini facelift experience rapid, natural looking results with very little recovery time.

The best candidates for a mini facelift are those in good health with mild to moderate lower facial and/or neck laxity. It is also effective as a follow-up procedure for patients who previously had full facelifts but desire additional rejuvenation of the face and/or neck area. The procedure does not preclude undergoing a full facelift in the future.

SMAS Lift
The SMAS lift is a more traditional facelifting technique designed to address extra skin and laxity of the neck, jowl and jaw line.SMAS refers to a supportive layer of tissue for the face that lies beneath the skin. By elevating the deeper SMAS tissue, tension is taken off of the skin edges, and a longer-lasting result of increased definition of the neck and jawline is achieved (when compared to a mini-lift). This procedure is commonly performed under local anesthesia in our in-office procedure room. However, since we are located within a full service hospital, the procedure may also be performed in the operating room under general anesthesia, depending on patient preference.
Deep Plane Facelift
The deep plane facelift is a more extensive operation that typically requires general anesthesia. The goal of the deep plane facelift is to accomplish additional lift of the midface or tissue of the upper cheeks.

Neck Lift
The neck lift (or “posterior mini facelift”) is for men and women concerned primarily about the appearance of their neck. The shape and contour of the neck are often associated with an aged appearance. However, the rejuvenation of this area is commonly overlooked.

Skin creams, laser treatments, Botox® and fillers are often used to treat early signs of facial aging. but they are less successful in improving the contour of the neck as compared to the appearance of the face.

There are multiple factors that contribute to an aged appearance of the neck. For some, it is the collection of excess fat under the jaw line, and for others, it is the visible sagging of excess skin causing what many patients refer to as their “turkey wattle.” In addition, there is often separation of the platysmal muscle with age, causing bands in the front of the neck.

The necklift procedure is a combination of multiple treatments, depending upon the needs of the individual patient. Liposuction may be used to remove a small amount of excess fat under the chin. For larger amounts of fat, a small incision is made under the chin to directly remove the problematic fat. To remove excess skin in the neck, a small incision is placed behind the ear to allow for reshaping of the neck and removal of excess skin. If anterior neckbands are a problem, then a small incision under the chin is made to allow the surgeon to bring the muscle back together in the midline, thereby eliminating the bands.

These procedures may be performed under local anesthesia and are often done in combination with other procedures as needed. You and your surgeon will determine what treatment is best for you.

Facial hollowing can occur because of weight loss or as a part of the normal aging process. An overly thin face can prematurely age one’s appearance. Fillers are commonly used to address this problem; however, some patients choose fat augmentation as a more permanent solution for their facial volume loss.

The procedure can be performed in the office alone or under anesthesia when performed in combination with a facelift. The fat is typically taken from the abdomen through a small incision in the belly button. No incisions are made on the face, only small needle sticks to allow the harvested fat to be placed in the appropriate areas of the face.

Hair loss is a common condition that affects both men and women, and can involve a receding hair line, balding in the crown region, overall thinning, loss of eyebrow hair, or traumatic hair loss from scars or skin cancer resections. Hair loss can have a significant impact on your appearance and often results in a loss of the self-confidence you once had.

Hair restoration surgery is a permanent solution that redistributes your own hair from the back of your scalp to the areas that need increased coverage. It is a very well tolerated procedure that is performed in a clinic setting, with minimal downtime required.

We offer permanent hair restoration treatment, with the safety of a hospital setting, at Mass. Eye and Ear, a Harvard Medical School teaching hospital. Our highly skilled surgeons have a particular passion for treating hair loss in both men and women, and we understand the importance of restoring someone’s confidence.

Understanding hair restoration
The most common cause of androgenic alopecia (or pattern baldness) is genetics. The hair follicles in the frontal and crown region are affected by the male hormone dihydrotestosterone (DHT), leading to hair loss in these regions.

The reason hair transplant can be successful and permanent is that hair from the posterior portion of the head is not affected by DHT hormone in the same way. Hair transplantation takes advantage of "donor dominance," meaning after posterior hairs are transplanted to the frontal or crown region, they continue to exhibit characteristics of permanent hair.

Determining if you are a good candidate for hair restoration
Although genetics are the most common cause of hair loss, patients who have scars or traumatic lesions also experience hair loss and may be candidates for hair restoration surgery. Eyebrows and traumatic areas of hair loss can be successfully transplanted.

During a complimentary first visit, Dr. Lee will take a full medical history and physical examination, with special attention to evaluating your hair loss pattern and potential success profile with hair transplant surgery. Your personal concerns and goals of surgery will be thoroughly discussed. If you are a good candidate, Dr. Lee will discuss the two methods of hair restoration surgery: follicular unit transplant (FUT – also known as the “strip technique”) and follicular unit extraction (FUE).

Understanding updated techniques in hair restoration
Major advances have been made in hair transplantation techniques over the past decade. Updated techniques utilize much smaller grafts called microfollicular units. These techniques include Follicular Unit Transplant (FUT) and Follicular Unit Extraction (FUE). Because of these updated techniques, surgeons are now able to create more natural improvements in the appearance of your hair. Patients are not left with obvious “plugs” or an unnatural hairline – both stigmas of outdated hair transplant techniques.

During your initial consultation, you will discuss the advantages and disadvantages of FUT versus FUE, and decide together which is most appropriate for your case.

In general, the advantages of FUT (strip technique) are:

More grafts can be transplanted in a single session

Shorter procedure time

Lower cost

No need to shave your head for the procedure. The suture line is well hidden immediately after your procedure

In general, advantages of the FUE are:

No suture line. If your preferred hairstyle is a shaved cut or a very short haircut, FUE can be preferred for this reason.

FUE can be performed in a very tight scalp, such as a patient who has undergone several prior hair transplants and has lost scalp laxity.

Medical therapies for hair loss
Medical therapies (such as Rogaine and Propecia) can be successful in preventing additional hair loss, but they cannot restore hair in areas that have already been affected. The only way to permanently restore hair is through hair restoration surgery, but medical therapies can be successfully used as a supplement to optimize the results of a hair transplant. If medically indicated, your surgeon will prescribe these for you.

What to expect
The procedure is very well tolerated and is performed under local anesthesia in the Facial Cosmetic Surgery Center at Mass Eye and Ear. Patients can either bring their favorite DVD's to watch during the procedure or select from our collection of movies and entertainment.

Snacks and lunch are provided. No postoperative dressings are required. Patients are encouraged to wash their hair the day after the procedure. Dr. Lee will follow the results with you at regular checkups.

For more information about hair restoration surgery or to schedule a consultation with Dr. Linda N. Lee, please call 617-573-4105.

Botox® and Neuromodulators (Dysport® and Xeomin®)
Botox® can improve the look of moderate to severe frown lines between the eyebrows (glabellar lines) and “crow’s feet” at the outside corners of the eyes. It can also create a smoother appearance to the skin surface by preventing muscle contraction.

Botox® is one brand name for clostridium botulinum. Other products, such as Dypsport® and Xeomin® can also be used to achieve the same results. Small, diluted amounts of this prescription medicine can be directly injected (using a very fine needle) into specific muscles, blocking signals from the facial nerves to the muscles, resulting in an inability of the muscles to contract. This causes existing wrinkles to relax and soften. Botox® typically reduces wrinkles by 80 percent.

Results are fully evident within one week. Lines will continue to improve for up to 30 days, and the effect lasts for three to four months.

Possible Side Effects
Botox injections are safe and quick. However, as with all cosmetic procedures there are possible side effects and risks associated with the injection. The most common side effects are discomfort or pain at the injection site, dry mouth, headache and flu-like symptoms. Infrequently, patients may have an allergic reaction to Botox®.

Hyaluronic Acid Fillers (Restylane®, Jevederm®, Voluma®, and Belotero®)
Collagen gives our skin its volume, flexibility and strength. As we age, collagen breaks down, reducing elasticity and facial volume, resulting in deep lines and wrinkles that are only deepened by the effects of gravity, time, wind and weather.

Hyaluronic acid fillers are natural cosmetic fillers that adhere to the skin as the water contained in the acid helps to retain volume under the skin’s surface. The acid acts as a magnet for water, which helps to preserve the renewed volume of the skin.

The product is injected under wrinkles and age lines of the face, such as the nasolabial folds, “crow’s feet” at the corners of the eyes, forehead wrinkles and lines around the mouth. It may also be used for filling age-related hollows and “orbital troughs” (hollowing around the eyes). It may also be used for lip augmentation.

Prior to the injection, the surgeon will usually numb the area either by the application of ice or with a local anesthetic. The filler is then injected with an ultra-fine needle, and most patients experience minimal discomfort. The procedure is fast and has a short recovery time.

Results from hyaluronic acid fillers are fully evident within one week and should last for about six months.
Hydroxylapatite Fillers (Radiesse®)
Radiesse is a popular wrinkle filler made from calcium hydroxyapatite, a naturally occurring substance in the body. Radiesse® may be used to replenish volume and smooth out smile and frown lines, while also shaping and contouring the face. Radiesse® also promotes the growth of the body's own collagen, to provide lasting, but not permanent, augmentation.

Prior to the injection, the surgeon will usually numb the area either by the application of ice or with a local anesthetic. Radiesse® is then injected with a small needle and most patients experience minimal discomfort.

Patients typically notice up to an 80 percent improvement immediately after treatment. Results from Radiesse® are fully evident within one week and should last around two years.

Poly-L-Lactic Acid Fillers (Sculptra®)
As we age, we can lose baby fat in the face which can exacerbate signs of aging. Sculptra (poly-L-Lactic acid) is a unique facial filler that can help restore the youthful appearance of your face by improving the contour and the tightness of your skin. It is particularly useful for treating hollowed appearing cheeks and temples. Sculptra has been called a "liquid facelift" because of its ability to provide a natural-looking lift to the cheeks and jowls. Different from all other traditional facial fillers, Sculptra works by stimulating your own body to make new collagen. The results are very gradual, and can last up to several years. Multiple treatments may be needed to achieve optimal results. After treatment, the patient should massage the affected areas for 5 days.

Possible Side Effects for Filler Injections
Filler injections are safe and quick. However, as with all cosmetic procedures, there are side effects and risks associated with the procedure. The most common side effects include discomfort or pain at the injection site (which usually subsides within 24 to 36 hours), bruising and infection. Patients are advised to stay out of the sun. A rare complication may be the appearance of nodules, which would require steroid treatment.

Some men and women are genetically pre-disposed to collect fat under the chin as they age. This submental fat may be removed with a procedure called “submental liposuction.” When addressed at an early age, the skin still has an abundance of collagen and elastin, allowing the skin to naturally retract to a more youthful contour after the fat is removed.

This treatment involves making a very small incision under the chin and behind each ear and removing the excess fat using a very small cannula. The incisions are placed in areas where a skin crease already exists to camouflage the scar. This is a minimally invasive procedure that may be performed under local anesthesia in our office procedure room to create a more youthful neck contour.
Liposuction of the neck is commonly performed at the time of a facelift to further refine the neckline.

The neck lift is for men and women concerned primarily about the appearance of their neck.The appearance of the neck is commonly a clear give away to your age; however, the neck is a commonly overlooked area. Skin creams, laser treatment, Botox, and fillers are treatments often used to treat early signs of facial aging but they are less successful in improving the contour of the neck as compared to the appearance of the face.
Common causes of the aging neck:

Collection of excess fat under the jaw line

Sagging of excess skin caused by the loss of skin elasticity with age

Relaxation of the platysma muscle causing anterior neck bands

Treatments are individualized to treat a patient’s specific cause of the aging neck. The necklift procedure is actually a combination of multiple treatments depending upon the needs of the individual patient. To remove a small amount of excess fat under the chin liposuction can be performed. For larger amounts of fat a small incision is made under the chin to directly remove the problematic fat. To remove excess skin in the neck a small incision is placed behind the ear to allow for recontouring of the neck and removal of excess skin. If anterior neckbands are a problem then a small incision under the chin is made to allow your surgeon to bring the muscle back together in the midline and thereby eliminating the bands. This procedure is known as a platysmal plication.

These procedures can be performed under local anesthesia and are often done in combination with other procedures as needed. You and your surgeon will determine what treatment is best for you.

Many patients are concerned with the fact that their ears stick too far away from their head and/or that they are missing the fold that others have in their ear (called the “anti-helical fold”).

Most otoplasty patients are children between the ages of four (when the ear is fully grown) and fourteen. The advantage of performing otoplasty at this young age is that the ear cartilage is very pliable and easily shaped. The procedure has been shown to offer psychological benefit to young children who have been teased about the size or shape of their ears. The second largest group of otoplasty patients are women and men in their 20s and 30s who have been bothered by the appearance of their ears for a long time and decide that they are now ready to improve the contour of their ears.

Otoplasty involves making an inconspicuous incision behind the ear, exposing the ear cartilage and re-positioning it closer to the head, and then to create folds in the cartilage that did not develop naturally on their own. The surgeon will use permanent sutures to retain the new shape of the ear. The small incisions behind the ear are then closed with dissolvable sutures.

Surgical Risks
Postoperatively, otoplasty patients experience very few side effects. However, all surgical procedures carry inherent risks, such as the possibility of infection or hematoma (a collection of blood caused by leakage from broken blood vessels). Abnormal scar tissue formation is also a possibility resulting in a visible scar behind the ear. There may also be pain, itching and some degree of numbness along the incision line.

Scars on the face can be noticeable and a distraction to daily communication. For some, scars may be an unsightly reminder of a previous injury and they may limit the function of daily activities such as eating, breathing and speaking. Frequently people wish to have their scars revised to not only improve their aesthetic appearance, but also their ability to function.

Once a scar forms, it is permanent; however, there are surgical and non-surgical techniques available to make a scar less visible, either by surgically relocating it or by minimizing its prominence. Mass. Eye and Ear offers the services of highly trained dermatologists and facial plastic and reconstructive surgeons to ensure that every opportunity is available to revise scars in the best possible manner.

Scar Treatment Techniques

Different types of scars often require different treatments. Because scars are highly individual, some may require more than one procedure and multiple techniques.

Steroid Injections

Steroids may be injected directly into the scar tissue to decrease the size of the scar and to alleviate any itching, redness and/or burning sensations. Steroid injections are often used in conjunction with surgery, and the injections may be continued for up to two years after the surgery to maximize healing and to prevent recurrence.

Laser Resurfacing

Laser resurfacing makes rough or elevated scars less prominent by removing part of the upper layers of skin with laser light. This technique may be used alone or in combination with surgical excision. Though most scars heal after excision without needing any further intervention, the laser can be helpful in those scars where redness (erythema) and/or elevation of the excision site have developed.

Excision

Primary excision of a scar is often a first consideration in surgical scar management. The scar tissue is excised and the skin edges are re-approximated with great precision, so the wound edges heal in a more favorable way than they did in the past.

Furthermore, long and prominent scars can be “broken up” or irregularized. This technique makes the resulting scar less visible to the eye, as multiple shorter segments replace one longer one.

Skin Flap

Skin flap procedures may be performed after scar tissue excision to further minimize the scar’s appearance. Adjacent, healthy skin is lifted and moved to form a new incision line.

Skin Graft

When a flap is not possible, a skin graft may be used. A graft involves taking a section of skin tissue from one area and attaching it to another. Time must be allowed following surgery for new blood vessels and soft tissue to form.

Z-plasty

Z-plasty is a method of scar relocation, usually moving the scar into a natural fold or skin crease with the aim to minimize its visibility. While Z-plasties do not remove all signs of a scar, it does make it less noticeable during daily communication.

Tissue Expansion

Tissue expansion is a technique used for scars that cover very large surface areas. Tissue expansion involves the placement of an expanding device that is slowly infused with saline over time, to stretch the overlying skin. When the device is removed, the additional tissue is then used to cover an area of large scar. This technique is often used in conjunction with skin flap surgery for large scars.

A scar should be analyzed with respect to its location, functional restrictions, and aesthetic location in the context of each individual patient. Then a comprehensive management plan for the scar can be developed to minimize its visibility.

If you would like a consultation to review the options for improvement in your scar, please call our Division of Facial Plastic and Reconstructive Surgery at 617-573-3223 to schedule an appointment with one of our physicians.